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SAN J OAQ U I N Environmental Health Department <br /> COUNTY- <br /> Greotness grows hr-. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1 . To be <br /> completed by APPLICANT <br /> Business Name pr Z:� ��, C, Pirc x, LL L Lic. Plate# <br /> Owner/Operator Name 421 <br /> Business Mailing Address I I I I m& ,✓l <br /> City State(P[Zip c/S Bus. Ph.1,4,6'11%�o-';tqo5 Alt. Ph.&a-j)_c,�b=T&3 <br /> I, 6(t�2'2r3 -x-cif}ic, , hereby state that the above information is current, true and correct to <br /> the best of my kno ledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signatur&�7�7 Date 0*0_q ( 7-0"L3 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Z��L�'�- C �i�!///Y/i'<, FA# <br /> Address &26 S Bus. Phone (20 9 )LJ 4q- 'F3'31/ <br /> City SDI Zip qr 2`O Owner/Operator <br /> Che all appropriate services provided: <br /> Wastewater disposal Imo" 3-compartment sink :�ectrical hook-ups <br /> �4s lid waste disposal Food preparation Toilet and handwashing <br /> VHjot & Cold water for cleaning St re refrigerated food Potable water <br /> Store dry food/supplies 'Overnight parking 0/'Vehicle wash <br /> hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food facility <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall notify the EHD immediately. <br /> Signature Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />